Changing partnership

Job patterns are changing

The nature of employment of general practitioners has been changing in recent years. Part time, job sharing, salaried, and short term contract work have all filtered through as viable options. Many general practitioners have also changed practice. A study of 300 nationwide practice vacancies found that 14% of the newly appointed partners had previously been a partner in another practice and 14% of the departing partners left to join another practice.(2) Established GP principals made 12% of all applications and there was no evidence of prejudice against GPs who wished to change partnerships.

Reasons to leave…

Disagreements with organisation and philosophy of the practice

Not getting on with partner/s

Desire to move locality

Inadequate income

Exploited by partner/s

…and stay

Financial reasons

Uncertainty and insecurity

Upheaval

Fear of unemployment

Leaving previous patients

Geographical relocation (if not desired)

General practice partnerships have been compared to marriage. Leaving a partnership is not easy and may be likened to obtaining a divorce in a business sense.

Perhaps the main disincentives to changing partnership are financial: unlike hospital doctors, moving and relocation expenses have to be found by the individual - it is unusual for the new practice to pay expenses. Loss of a parity income is a further problem to consider.

Moving causes much upheaval, which may involve uprooting the family, leaving friends, spouse's job, schools, and social disruption. One doctor felt that changing practices meant throwing away the investment of many years' effort. You are unable to stand on your reputation and have to earn it again.(3)

You may be able to identify and address problems in your practice without taking the drastic step of moving. Altering workload patterns, improving communication between partners, and some reorganisation in the practice may resolve differences. Out of hours cover has been a burden for many practitioners, but the recent mushrooming of cooperatives has reduced stress levels for many in this area. If the practice income is inadequate there may be other ways of improving this without leaving the practice to start again.

Clearly, all of the relevant factors must be weighed before a decision to leave is implemented.

Leaving the practice

Careful planning is needed if a practice is to minimise the potential disruption that can occur when a partner leaves.(4) Informing the partners, staff, and patients needs delicate handling, both in terms of timing and method.

Your partners will need as much warning as possible to adjust and consider the alternatives. Adequate time will allow planning for a replacement appointment and a mutually acceptable departure date.

The practice staff will need to be told, preferably before they hear it on the local grapevine, and they will need guidance on how to inform others, including patients, who make inquiries or want to book appointments. They could be briefed at a meeting or it may be preferable to speak individually to them. Patients will inevitably ask them why you are leaving and where you are going. The staff should receive guidance on how to answer these queries.

Informing the patients is important and can be carried out in several different ways, including face to face information, a notice in the waiting room, or a slow leak on the grapevine, though this last method is best avoided: inaccurate rumour or exaggeration are almost inevitable. A partnership change can result in considerable expense for the practice: it will involve the accountant, solicitor, advertising, and interviewing, not to mention the time and effort that goes into organising the change and appointing a new partner.

Legal aspects

It may be necessary to brush the dust off the partnership agreement if it hasn't seen the light of day for sometime as there are a number of areas in which the agreement should be consulted when planning a move.

Financial extrication from the practice can be difficult and protracted, particularly if a share of the practice premises is involved. A clear description of the arrangements for paying a departing partner his or her share of the practice equity should form part of the agreement, and should include the timing of payments and method of valuation of any property involved.

A restrictive covenant is likely to be included, which will only be relevant if the doctor is moving to a nearby practice. Some covenants are unreasonably restrictive and may not in fact be enforceable. The partnership agreement will also state the required period of notice that has to be given to the remaining partners, which may be longer than that required by the health authority.

Objective evidence to help the decision

My recent study sought the views of over 200 GP principals who had changed practice, of whom around 40% had moved into singlehanded practice.(5) Previous experience as a GP principal was widely seen as an asset when these doctors applied for their current post. They were better able to assess a practice and state priorities, as well as being more aware of potential problems and pitfalls. They were able to bring greater skills into their new post, especially for the administrative and business aspects of general practice. The greatest perceived benefit was for those who had moved into singlehanded practice and become their own boss. They enjoyed new found freedom in decision making and complete control of practice organisation.

Advantages of a new post…

Benefits of previous experience

Autonomy in singlehanded practice

Improved income

Better locality

Better working

…and disadvantages

Loss of income

Higher workload

Locum cover if singlehanded practice

Re-establishing yourself

Onerous on call arrangements

The main disadvantage of moving was loss of a parity income, although this was only temporary for some. A higher workload was reported, particularly for singlehanded doctors, who had difficulty finding cover for sickness and holidays.

Establishing new relationships with colleagues and practice staff, and gaining the confidence of a new list of patients was also seen as a substantial disadvantage compared with staying put.

The pros and cons will vary depending on your own circumstances and choice of practice. Over 90% of the GPs who moved practices in this study were very satisfied with their move and felt that it had been successful. Most of the younger doctors said that they would consider moving again and only 5% would not recommend changing practices to a colleague.

Future trends

In many careers the concept of a single job for life is disappearing, and employment is less secure. Many young people in other walks of life expect to change jobs every few years: a combination of global competitio and fast moving technology may compel them to make three or four career changes too.(7) People will have to package themselves for the job market and concentrate on building skills that make them employable.

General practice has entered a period of rapid change and uncertainty. It is likely that we will see an increase in the number of GPs moving partnership, for several reasons.

Firstly, the topic of moving is no longer taboo. It is being discussed more widely in the medical press and has become more acceptable. Guidelines on how to leave a practice are now available.(4)

Secondly, GPs cope in a highly individual way with the increased demands of the 1990 contract, fundholding, and planned changes such as deregulation. These changes are likely to put more pressure on the cohesion of partnerships with an increased chance of partnership splits or partners wanting to leave.

Finally, recruitment to some partnership vacancies has become more difficult, so with fewer applicants for each job there is more chance that a GP principal will be considered.

Current evidence suggests that a move of practice is likely to be both successful and satisfying, although not entirely free from problems.